HomeMy WebLinkAboutBLDP-23-005662 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
, g k,,,,, +a CITY YARMOUTH MA DATE 4/11/23 PERMIT# BLDP-23-005662
_-h � JOBSITE ADDRESS 4111 HEATHERWOOD OWNERS NAME TRAUB TIMOTHY T TR
P OWNER ADDRESS CIO DONLAN MARGARET P 4111 HEATHERWOOD YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO m
FIXTURES 1 FLOORS. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES m NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General
Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Paul Gorgone LICENSE 20873 SIGNATURE
MP 0 JP ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME PAUL R GORGONE ADDRESS PO BOX 1566 11 FROG TREE LANE
CITY EAST DENNIS STATE MA ZIP 026411566 TEL
FAX CELL EMAIL paulgorgone@gmail.com
5—U
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�_��� CITY a- .)-4.-
IM hlMA DATE tt/ h__ PERMIT#" /'Z3 -a S(
JOBSITE ADDRESS 11 ( I ( 19- er--.dam D OWNER'S NAME PAT 170,-)j cLV
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑r PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _ ----
DEDICATED SPECIAL WASTE SYSTEM - -
DEDICATED GAS/OIL/SAND SYSTEM 1
DEDICATED GREASE SYSTEM -PI' E iC E ' I) 7
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM A2 1 2D2
DISHWASHER --�
DRINKING FOUNTAIN g�i ,in DE LIT
FOOD DISPOSER By
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY .
ROOF DRAIN
SHOWER STALL I _
SERVICE/MOP SINK
TOILET
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER - -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES4 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY TB- OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
' CHECK ONE ONLY: OWNER ❑ AGENT 1-
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac• e to the best. 1 y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian., ,11 - P= -nt pri '_ .n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# d�93 SIGNATURE
MP❑ JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME (O1/4-.0 v in C_ y"P--171 ADDRESS , k /09 - 27
CITY 77e.✓f✓.- '"5 STATE vlei 6- ZIP D2_110 3C. TEL 97.k Cd - / cl l
FAX CELL EMAIL